MO Insurance Bulletin 2011-01: Insurance coverage for autism and autism spectrum disorders

INSURANCE BULLETIN 11-01

Insurance coverage for autism and autism spectrum disorders

Issued Jan. 3, 2011

To:

Health insurance companies, health service corporations, health maintenance

organizations, third party administrators, medical providers and the public

From: John M. Huff, Director

Re:

Section 376.1224, insurance coverage for autism and autism spectrum disorders

In the 2010 legislative session, the Missouri legislature enacted House Bills 1311 and

1341, which mandate insurance coverage for various treatments for autism and autism

spectrum disorders, in addition to establishing a licensure process for certain providers of

autism services.

The insurance coverage provisions of the legislation go into effect for policies which are

written, issued, or renewed on or after Jan. 1, 2011.

As the insurance industry implements the provisions of this law, the Department has been

asked to provide guidance to the industry and the public as to certain provisions of the

law.

Claim coding

The Department is not aware of established procedural codes specific to Applied

Behavior Analysis (ABA). Medical providers and the insurance industry rely upon these

procedural codes to effectuate the billing and payment of insurance claims.

The Department has been advised that a majority of the top 10 insurance companies in

the state of Missouri intend to rely upon HCPCS (Healthcare Common Procedure Coding

System) Codes H0031, H0032, H2012, and H2019 for billing and payment of insurance

claims related to ABA therapy.

Code

Long description

H0031

Mental health assessment, by non-physician

H0032

Mental health service plan development by non-physician

H2012

Behavioral health day treatment, per hour

H2019

Therapeutic behavioral services, per 15 minutes

By the issuance of this bulletin, the Department wishes to acknowledge and publicize the

prevalent reliance upon these HCPCS codes and encourage the industry to, wherever

possible, recognize and accept these procedural codes

H0032

Mental health service plan development by non-physician

H2012

Behavioral health day treatment, per hour

H2019

Therapeutic behavioral services, per 15 minutes

By the issuance of this bulletin, the Department wishes to acknowledge and publicize the

prevalent reliance upon these HCPCS codes and encourage the industry to, wherever

possible, recognize and accept these procedural codes. The usage of these codes will

provide uniformity within the industry and will also reduce confusion within the medical

provider community.

If any insurance companies are not able to utilize these HCPCS codes, the Department

encourages these companies to make information readily available to providers, both in-

and out-of-network, to disclose what codes providers should utilize for ABA services to

facilitate the prompt processing and payment of claims.

Failure to provide care and improper claim denials

The Department remains concerned about and will closely monitor the delivery of autism

related services and consumer complaints to ensure no unnecessary barriers to medically

necessary treatment or coverage restrictions are imposed by any insurance company.

This would include denials based upon a mere administrative technicality, such as if a

provider or insured provides all of the essential information necessary to review or

evaluate a claim or treatment, but fails to complete a specific form. Any consumer or

provider complaints received by Consumer Affairs that indicate inappropriate denials or

coverage restrictions will be immediately forwarded to the Market Conduct Section for

investigation and the company may be subject to an enforcement action.

Transitional and implementation concerns

The Department has also received inquiries from parents and providers as to what will

happen on Jan. 1, 2011, to those children that are currently receiving treatments for

autism or autism spectrum disorders, including ABA therapy

ediately forwarded to the Market Conduct Section for

investigation and the company may be subject to an enforcement action.

Transitional and implementation concerns

The Department has also received inquiries from parents and providers as to what will

happen on Jan. 1, 2011, to those children that are currently receiving treatments for

autism or autism spectrum disorders, including ABA therapy. There is a concern that

children in this situation may face an interruption in treatment. An interruption may occur

while transitioning to the new coverage available under Section 374.1224 RSMo., while

the provider seeks licensure under the new law or while the provider is completing the

provider credentialing process.

The Department encourages companies to exercise flexibility in accommodating children

in these situations. Companies can make accommodations for providers who have

undertaken the measures necessary to become licensed and/or credentialed. Companies

may also choose to waive existing prior authorization or pre-certification requirements,

relying instead upon retrospective reviews for determinations of medical necessity.

The Department encourages and welcomes such accommodations to help ensure that

those children currently undergoing treatment will not see an interruption in their

treatment on or immediately after Jan. 1, 2011. For those carriers instituting a temporary

modification or deviation to their practices or procedures to accommodate these

individuals, the Department will extend a “safe harbor” of one year from the date of this

bulletin from any enforcement or disciplinary action related to those temporary

modifications or deviations.